Statistical issues in the prospective monitoring of health outcomes across multiple units

Summary.  Following several recent inquiries in the UK into medical malpractice and failures to deliver appropriate standards of health care, there is pressure to introduce formal monitoring of performance outcomes routinely throughout the National Health Service. Statistical process control (SPC) charts have been widely used to monitor medical outcomes in a variety of contexts and have been specifically advocated for use in clinical governance. However, previous applications of SPC charts in medical monitoring have focused on surveillance of a single process over time. We consider some of the methodological and practical aspects that surround the routine surveillance of health outcomes and, in particular, we focus on two important methodological issues that arise when attempting to extend SPC charts to monitor outcomes at more than one unit simultaneously (where a unit could be, for example, a surgeon, general practitioner or hospital): the need to acknowledge the inevitable between-unit variation in 'acceptable' performance outcomes due to the net effect of many small unmeasured sources of variation (e.g. unmeasured case mix and data errors) and the problem of multiple testing over units as well as time. We address the former by using quasi-likelihood estimates of overdispersion, and the latter by using recently developed methods based on estimation of false discovery rates. We present an application of our approach to annual monitoring 'all-cause' mortality data between 1995 and 2000 from 169 National Health Service hospital trusts in England and Wales.     

Private placements in social work education: Opportunity or oppression?

This article examines the issues arising from student placements in the private or commercial sector. It focuses on private residential care for adults, as the most developed area of private provision in the UK, and explores the background to this form of provision. The article then considers the private sector placement from the viewpoints of the student, the private sector agency and the educational institution. A checklist for social work educators considering placements in the private sector draws together some of the key issues. The article ends with a discussion of the pragmatic, moral, logistic and educational perspectives which influence attitudes towards the private sector.     

Emotional labour: skill and work in the social regulation of feelings

I define emotional labour as the labour involved in dealing with other peoples’feelings, a core component of which is the regulation of emotions. The aims of the paper are firstly to suggest that the expression of feelings is a central problem of capital and paid work and secondly to highlight the contradictions of emotions at work. To begin with I argue that ‘emotion’is a subject area fitting for inclusion in academic discussion, and that the expression of emotions is regulated by a form of labour. In the section ‘Emotion at home’I suggest that emotional labour is used to lay the foundations of a social expression of emotion in the privacy of the domestic domain. However the forms emotional labour takes and the skills it involves leave women subordinated as unskilled and stigmatised as emotional. In the section ‘Emotion at work’I argue that emotional labour is also a commodity. Though it may remain invisible or poorly paid, emotional labour facilitates and regulates the expression of emotion in the public domain. Studies of home and the workplace are used to begin the process of recording the work carried out in managing emotions and drawing attention to its significance in the social reproduction of labour power and social relations of production.     

Ecological regression analysis of environmental benzene exposure and childhood leukaemia: sensitivity to data inaccuracies, geographical scale and ecological bias

Benzene is classified as a group 1 human carcinogen by the International Agency for Research on Cancer, and it is now accepted that occupational exposure is associated with an increased risk of various leukaemias. However, occupational exposure accounts for less than 1% of all benzene exposures, the major sources being cigarette smoking and vehicle exhaust emissions. Whether such low level exposures to environmental benzene are also associated with the risk of leukaemia is currently not known. In this study, we investigate the relationship between benzene emissions arising from outdoor sources (predominantly road traffic and petrol stations) and the incidence of childhood leukaemia in Greater London. An ecological design was used because of the rarity of the disease, the difficulty of obtaining individual level measurements of benzene exposure and the availability of data. However, some methodological difficulties were encountered, including problems of case registration errors, the choice of geographical areas for analysis, exposure measurement errors and ecological bias. We use a Bayesian hierarchical modelling framework to address these issues, and we investigate the sensitivity of our inference to various modelling assumptions.     

A review of midwifery in mainland China: Contemporary developments within historical,economic and sociopolitical contexts

Background

With the recent surging economic and social development in China, midwifery has undergone transformation.